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OBJECTIVES: Elite rugby union players face numerous physiological and psychological stressors which can increase upper respiratory and gastrointestinal illness risk, and in turn can compromise training and competitive performance. This study aimed to investigate the effect of daily prebiotic supplementation on upper respiratory symptoms, gastrointestinal symptoms, and markers of immune function in elite rugby union players. METHODS: Thirty-three elite rugby union players were randomly assigned to consume a prebiotic (2.8 g/day galactooligosaccharide) or placebo (2.8 g/day maltodextrin), daily for 168 days under double-blind conditions. Participants completed daily and weekly questionnaires for self-reported upper respiratory and gastrointestinal symptoms respectively. Blood and saliva samples were collected at 0, 84, and 168 days for assessment of plasma TNF-α and CRP, and saliva IgA respectively. RESULTS: The prebiotic group experienced a 2-day reduction in upper respiratory symptom duration (P = 0.045). Gastrointestinal symptom severity and incidence were lower in the prebiotic group compared to the placebo group (P < 0.001, P = 0.041) respectively. Salivary immunoglobulin A secretion rate was 42% greater in the prebiotic group compared to the placebo group at day 168 (P = 0.004), no differences in CRP and TNF-α were found (P > 0.05). CONCLUSION: A 168-day dietary prebiotic intervention reduced the duration of upper respiratory symptoms and reduced the incidence and severity of gastrointestinal symptoms in elite rugby union players. These findings suggest that seasonal prebiotic interventions may be beneficial for reducing illness in elite rugby union players, improving their availability to train and compete.Key pointsElite athletes are susceptible to upper respiratory symptoms and gastrointestinal symptoms which may impact upon training availability and competition performance.For the first time, this study shows that a dietary prebiotic intervention can reduce the duration of upper respiratory symptoms by 2 days in elite rugby union players.Dietary prebiotic supplementation can improve the incidence and severity of gastrointestinal symptoms experienced by elite rugby union players.Prebiotic supplementation was able to increase salivary IgA secretion after 168 days.These findings can inform practice suggesting that seasonal prebiotic use has the potential to modulate immune function and reduce illness in elite rugby union, which may improve a player's availability to train and compete.The mechanisms by which prebiotics reduce URS and GIS require further research exploration.

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The purpose of this study was to undertake a retrospective cross-sectional analysis to compare the frequency and characteristics of facial injury presentations at a UK and an Australian tertiary referral hospital during the implementation of COVID-19 social-distancing measures. The primary predictor variables were a heterogeneous set of factors grouped into logical categories: demographics, injury mechanisms and site, and management. The primary outcome variable was the presentation of a hard or soft tissue facial injury. A descriptive statistical analysis was undertaken on the assembled data. The study found a clinical and statistically significant reduction in the frequency (absolute number) of facial injuries at each study site. In addition, a striking similarity common in both countries was an increase in the number of facial injuries due to falls and a reduction in facial injuries due to interpersonal violence. Conservative (non-operative) management of facial injury increased at both sites. The implementation of COVID-19 social-distancing public health measures, which aimed to limit community transmission of the coronavirus, had a secondary serendipitous effect of reducing the frequency of facial injury presentations and altering their epidemiological characteristics at both a UK and Australian tertiary referral hospital.

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The eighth edition of the Union for International Cancer Control (UICC) staging manual was recently introduced. The staging of oral cavity squamous cell carcinoma saw changes in relation to depth of invasion and extra-nodal extension. We aimed to evaluate this system and its prognostic ability in a UK cohort. A retrospective review was undertaken of patients diagnosed with squamous cell carcinoma (SCC) of the oral cavity between January 2009 and December 2013. Data were collected on demographics, histology, and recurrence-free (RFS) and five-year overall survival (OS). Patients were staged using both the seventh and eighth editions of the UICC staging manual. Stage-specific survival analysis was performed using the Kaplan-Meier method. A total of 191 records were reviewed and 87 were included in the analysis. The mean (range) age was 60 (37-88) years, and 53% were male. The tongue was the most common site (51%). Using the seventh edition patients were staged as stage I=30, II=14, III=7, IVa=35, and IVb=1. Applying the eighth edition, 26 patients (30%) were upstaged (I=24, II=15, III=14, IVa=17, IVb=17). Ten were upstaged based on pT and 16 on pN status. Both staging manuals showed statistically significant discrimination between stages for both OS and RFS. Patients upstaged from stage IVa in the seventh edition had significantly worse OS in the new system (p=0.043). Both staging systems discriminated accurately between stages. Patients upstaged in stage IVa showed significantly worse OS suggesting improved prognostication with the eighth edition and the changes introduced.

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The intestinal microbiota of the horse, an animal of huge economic and social importance worldwide, is essential to the health of the animal. Understanding the intestinal ecosystem and its dynamic interaction with diet and dietary supplements currently requires the use of experimental animals, with consequent welfare and financial constraints. Here, we describe the development and assessment, using multiple analytical platforms, of a three-vessel, continuous-flow, in vitro model of the equine hindgut. After inoculation of the model with fresh horse feces, the bacterial communities established in each vessel had a taxonomic distribution similar to that of the source animal. Short-chain fatty acid (SCFA) and branched-chain fatty acid (BCFA) production within the model at steady state was consistent with the expected bacterial function, although higher concentrations of some SCFA/BCFA relative to those in the ex vivo gut content were apparent. We demonstrate the intermodel repeatability and the ability of the model to capture some aspects of individual variation in bacterial community profiles. The findings of this proof-of-concept study, including recognition of the limitions of the model, support its future development as a tool for investigating the impact of disease, nutrition, dietary supplementation, and medication on the equine intestinal microbiota.IMPORTANCE The equine gut model that we have developed and describe has the potential to facilitate the exploration of how the equine gut microbiota is affected by diet, disease, and medication. It is a convenient, cost-effective, and welfare-friendly alternative to in vivo research models.

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There are a growing number of older patients who are retaining their natural teeth. Though the majority of these patients remain independent, many are affected by frailty, multi-morbidity or dementia. The complexities associated with dementia have led to guidelines being produced by the FGDP, Dementia friendly dentistry, although other features of ageing can similarly increase the risk of dental disease and the consequent complexity, safety and suitability of providing treatment. Prevention of dental disease is crucial for older patients as the features of ageing may make the risk of treatment greater than that of younger patients. Conscious sedation or general anaesthesia, typically provided by a specialist dental service, may be required to facilitate treatment, though these approaches may have significant short and long-term impacts on older patients. Clinical guidelines and legislation are available to assist in decision-making for patients who may lack mental capacity, yet for patients who are able to consent for treatment, a comprehensive discussion as part of an informed consent process remains crucial to determine the most appropriate approach to care provision.

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Surgical tracheostomy is a commonly provided service by surgical teams for patients in intensive care where percutaneous dilatational tracheostomy is contraindicated. A number of factors may interfere with its provision on shared emergency operating lists, potentially prolonging the stay in intensive care. We undertook a two-part project to examine the factors that might delay provision of surgical tracheostomy in the intensive care unit. The first part was a prospective audit of practice within the University Hospital Coventry. This was followed by a telephone survey of oral and maxillofacial surgery units throughout the UK. In the intensive care unit at University Hospital Coventry, of 39 referrals, 21 (53.8%) were delayed beyond 24 hours. There was a mean (standard deviation) time to delay of 2.2 days (0.9 days) and the most common cause of delay was surgeon decision, accounting for 13 (61.9%) delays. From a telephone survey of 140 units nationwide, 40 (28.4%) were regularly involved in the provision of surgical tracheostomies for intensive care and 17 (42.5%) experienced delays beyond 24 hours, owing to a combination of theatre availability (76.5%) and surgeon availability (47.1%). There is case for having a dedicated tracheostomy team and provisional theatre slot to optimise patient outcomes and reduce delays. We aim to implement such a move within our unit and audit the outcomes prospectively following this change.

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BACKGROUND: Considerable racial and socio-economic disparities exist in breast cancer. In spite of the existence of numerous evidence-based interventions (EBIs) aimed at reducing breast cancer screening barriers among the underserved, there is a lack of uptake or sub-optimal uptake of EBIs in community and clinical settings. This study evaluates a theoretically based, systematically designed implementation strategy to support adoption and implementation of a patient navigation-based intervention, called Peace of Mind Program (PMP), aimed at improving breast cancer screening among underserved women. METHODS/DESIGN: The PMP will be offered to federally qualified health centers and charity clinics in the Greater Houston area using a non-randomized stepped wedge design. Due to practical constraints of implementing and adopting in the real-world, randomization of start times and blinding will not be used. Any potential confounding or bias will be controlled in the analysis. Outcomes such as appointment adherence, patient referral to diagnostics, time to diagnostic referral, patient referral to treatment, time to treatment referral, and budget impact of the intervention will be assessed. Assessment of constructs from the consolidated framework for implementation research (CFIR) will be assessed during implementation and at the end of the study (sustainment) from each participating clinic. Data will be analyzed using descriptive statistics (chi-square tests) and generalized estimating equations (GEE). DISCUSSION: While parallel group randomized controlled trials (RCT) are considered the gold standard for evaluating EBI efficacy, withholding an effective EBI in practice can be both unethical and/or impractical. The stepped wedge design addresses this issue by enabling all clinics to eventually receive the EBI during the study and allowing each clinic to serve as its own control, while maintaining strong internal validity. We expect that the PMP will prove to be a feasible and successful strategy for reducing appointment no-shows in underserved women. CLINICAL TRIALS REGISTRATION NUMBER: NCT02296177.

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The human gut is a complex ecosystem occupied by a diverse microbial community. Modulation of this microbiota impacts health and disease. The definitive way to investigate the impact of dietary intervention on the gut microbiota is a human trial. However, human trials are expensive and can be difficult to control; thus, initial screening is desirable. Utilization of a range of in vitro and in vivo models means that useful information can be gathered prior to the necessity for human intervention. This review discusses the benefits and limitations of these approaches.

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BACKGROUND: Major haemorrhage is a catastrophic complication occurring in 3-4 per cent of head and neck cancer patients. Massive haemorrhage also causes 50 per cent of preventable deaths in combat situations. There has been a surge of interest in the development of effective haemostatic products in the military, with chitosan being one such product. CASE REPORT: A 48-year-old lady presented with a life-threatening head and neck bleed. She was known to have a malignant peripheral nerve sheath sarcoma originating from the left parapharyngeal space. Bleeding was successfully controlled with the application of Celox™ granules, a chitosan-based product currently used in the military. CONCLUSION: This paper describes the first known use of a military haemostatic agent to control a malignant head and neck bleed. Celox granules can be poured directly onto a wound to enhance haemorrhage control. The suggested mechanism of action and reports of current uses of haemostatic agents are described.

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OBJECTIVE: Variant anatomy of the hypoglossal nerve is very rare. We report an unusual intra-operative finding of an aberrant branch of the hypoglossal nerve, encountered during a facial reanimation procedure. CASE REPORT: A 50-year-old man was referred to the head and neck surgery department by the neurosurgeons for hypoglossal-facial nerve anastomosis to treat his facial paralysis, which had occurred following the removal of an intracranial neoplasm. During surgery, we identified an aberrant branch of the hypoglossal nerve, which took a more ventral and superior course in the carotid triangle, prior to entering the base of the tongue. Following further dissection, we found the main trunk of the 'true' hypoglossal nerve. Several interconnecting strands were seen in the proximal aspect of both the aberrant branch and the main trunk of the hypoglossal nerve. These interconnecting fibres appeared to have tethered the main trunk into an abnormal anatomical position. CONCLUSION: As far as we can ascertain, this is the first report of an aberrant branch of the hypoglossal nerve. Although this variant would appear to be extremely rare, surgeons must consider all variations of this nerve during head and neck procedures, in order to minimise iatrogenic complications.

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INTRODUCTION: A rare but significant cause for stroke is sub-intimal carotid dissection and this mechanism accounts for approximately 2.5% of all strokes.(1) Dissection of the carotid artery is often caused by trauma to the face or neck.(2) Under 45 years old, it is the second leading cause of stroke.(3) Neurological symptoms can be lacking or subtle, therefore the condition may be overlooked but the pathological processed is believed to be attributed to thromboembolism.(4) Microemboli in the middle cerebral artery, are known as a risk factor for ischaemic stroke following a transient ischaemic attack (TIA) and can be detected by transcranial Doppler examination (TCD).(5) The established treatment regime is antiplatelet therapy, anticoagulation or both along with supportive therapy.(6) Current evidence suggests managing microemboli in both crescendo TIA's and post carotid endarterectomy improves outcome.(7) We have found the use of Tirofiban, a potent intravenous antiplatelet agent currently licensed for use in acute coronary syndrome, effective in the treatment of microemboli in this manner.(7) CASE PRESENTATION: We report a case of symptomatic carotid artery dissection post radical neck dissection, causing TCD detected microemboli and successfully treated with Tirofiban. CONCLUSION: We believe further study into the use of Tirofiban in the treatment of microemboli after carotid dissection is indicated.

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The authors have adopted a set pattern of colour coded vascular sloops that they use to identify and isolate vital structures in the head and neck. This simple and cost-effective technique aids vascular control and has applications in elective head and neck surgery, as well as in controlling haemorrhage secondary to trauma.

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OBJECTIVE: We tested the hypothesis that a set of differentially expressed genes could be used to classify mice according to cardiovascular phenotype after prolonged catecholamine stress. DESIGN: Prospective, randomized study. SETTING: University-based research laboratory. SUBJECTS: One hundred seventy-three male mice were studied: wild-type (WT) C57, WT FVB, WT B6129SF2/J, and beta2 adrenergic receptor knockout. INTERVENTIONS: Mice of each genotype were randomly assigned to 14-day infusions of isoproterenol (120 microg/g/day) or no treatment. Approximately half of the animals underwent left ventricle pressure volume loop analysis. The remaining animals were killed for extraction of messenger RNA from whole heart preparations for microarray analysis. MEASUREMENTS AND MAIN RESULTS: We observed that WT FVB and beta2 adrenergic receptor knockout mice developed systolic dysfunction in response to continuous catecholamine infusion, whereas WT C57 mice developed diastolic dysfunction. Using these mice as the derivation cohort, we identified a set of 83 genes whose differential expression correlated with left ventricle systolic dysfunction. The gene set was then used to accurately classify mice from a separate group (WT B6129SF2/J) into the cohort that developed left ventricle systolic dysfunction after catecholamine stress. CONCLUSIONS: The differential expression pattern of 83 genes can be used to accurately classify mice according to physiological phenotype after catecholamine stress.

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This case report describes the development of a post-treatment enlargement of the sternoclavicular joint, diagnosed as a pseudo-tumour, in a patient who had previously undergone radical neck dissection and post-operative radiotherapy for metastatic mucoepidermoid carcinoma. Although pseudo-tumour has been previously reported in the surgical literature, it remains an uncommonly recognized condition. We present a review of the literature and discuss the condition's pathogenesis. We also highlight its importance to both the surgeon and the oncologist when considering the differential diagnosis of a swelling in the clavicular region, typically occurring following radical surgery for malignant disease in the neck.

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